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physician profile fact sheet 2009 _electronic_

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					                            CONTINUUM HEALTH PARTNERS
                                Physician Profile Fact Sheet

All physicians affiliated with any one of the Continuum Health Partners hospitals are invited to
complete this Profile Fact Sheet. The information on this fact sheet is made available to the
public on Continuum’s web site, www.chpnyc.org. Additionally, it is used by individuals who
call our Physician Referral Center (800-420-4004) for a medical referral and for Continuum’s
Physician Telephone Directory.

In addition to this form, we need a copy of your CV. Please send this form
and your CV, by fax or email to:
                      Ms. Janice Boylan
                      Continuum Referral Service
                      555 West 57th Street, 18th Floor
                      New York, NY 10019
                      Phone: (212) 844-1844
                      Fax: (212) 420-2180
                      Jboylan@chpnet.org
______________________________________________________________________________
   New Listing                                         Change in current information
   Please post my information on Continuum’s Web site, www.chpnyc.org
   Please include my information in the medical referrals you provide at the Physician Referral
Service

Last Name:                     First Name:              Middle Initial:
______________________________________________________________________________
E-Mail: To facilitate faster and more efficient communications with members of the medical
staff, we ask that you provide your E-mail address. Please be assured that your e-mail address
will be used strictly for internal communications, unless you indicate that it should be posted
on our Web site. We will not share your E-mail address with any outside source.

Your E-mail address:
   Do not post on www.chpnyc.org       Post on www.chpnyc.org for public viewing
______________________________________________________________________________

Professional Certification (MD, DDS, DO, etc.)
Gender: Male      Female

Board Certified:     Yes      No                    Board Certified:      Yes      No
Board Eligible:     Yes      No                     Board Eligible:      Yes      No

Board Name                                          Board Name
Year Certified                                      Year Certified
Year Recertified                                    Year Recertified
______________________________________________________________________________

Hospital Affiliation(s): BI (Petrie) BI (KHD)  SLR    LICH     NYEEI
Department:
Specialty: (Primary)
Specialty: (Secondary)
Clinical Interest(s):
______________________________________________________________________________
_______________

Medical Staff Rank and/or Title(s): Check all that apply. Titles refer only to Continuum
hospitals.

 Chairman, Department of
 Chief, Division of
 Director, (Center)
 Attending
 Other
______________________________________________________________________________

Academic Appointments: Indicate academic titles only for institutions listed below.

   Albert Einstein College of Medicine
   Columbia University College of Physicians and Surgeons
   SUNY Health Science Center (Brooklyn)
   New York Medical College

Title                                     Department
______________________________________________________________________________

Medical School
Location                  Year Graduated

Residency Program:               From          (year) to      (year)
Location (hospital, city, state)

Residency Program:               From          (year) to      (year)
Location (hospital, city, state)

Fellowship          From           (year) to         (year)
Location (hospital, city, state)

Fellowship           From          (year) to         (year)
Location (hospital, city, state)

If you wish, you may attach a photo for our Web site, www.chpnyc.org
Photo attached:    Yes        No
______________________________________________________________________________

Office Information: Please complete for each office in which you practice – attach any
additional information.

Office Address 1                                    Office Address 2
Practice Name                                       Practice Name
Street                                              Street
City       State       Zip                          City       State       Zip
Telephone:                                          Telephone:
Fax                                                 Fax
Office Manager/ Phone:                              Office Manager/ Phone:

Office Schedule                                     Office Schedule
Monday             to                               Monday             to
Tuesday             to                              Tuesday             to
Wednesday           to                              Wednesday           to
Thursday             to                             Thursday             to
Friday             to                               Friday             to
Saturday           to                               Saturday           to
Sunday             to                               Sunday             to

Are you willing to see emergency cases?       Yes       No
Are you willing to make housecalls?       Yes       No
Are you in a group practice?       Yes       No
If yes, please list other physicians’ names:
Please note any specific equipment you have on site (e.g., X-ray, sonogram)?
Is your office handicap accessible?      Yes      No
Please list any languages you speak other than English:
Please list any languages your staff speaks other than English:
Do you accept children?        Yes       No
If yes, what is the youngest age?
______________________________________________________________________________

Payment Information:
Please provide us with a listing of all of the insurance plans you accept. Be sure to include
information as to whether you accept Medicare and/or Medicaid, including any managed-care
Medicare/Medicaid plans.

Initial visit fee $    Subsequent visit fee $
Do you require payment at time of service?    Yes        No

Do you accept Medicare as a primary payor?
   Yes        No
Do you accept Medicaid as a primary payor?
    Yes       No
If no, do you accept Medicaid as a secondary payor?
    Yes       No
Please check any insurance plans you accept: (Attach additional page if necessary)
   1199                           DELTA DENTAL                      HIP MEDICAID
   32 BJ                          ELDERPLAN                         HIP PPO
   ACADEMIC HEALTH                EMPIRE BLUE                       HIP VIP (Medicare)
PLAN (Yeshiva Students)         CROSS/BLUE SHIELD EPO               HIP/VYTRA
   AETNA CHICKERING               EMPIRE BLUE                       HORIZON BLUE CROSS
(Columbia University Student    CROSS/BLUE SHIELD HMO            BLUE SHIELD OF NJ
Insurance)                        EMPIRE BLUE                       HOTEL TRADE UNION
   AETNA MEDICARE               CROSS/BLUE SHIELD                   HUMANA
   AETNA NYC                    INDEMNITY                           LOCAL 814
COMMUNITY PLAN                    EMPIRE BLUE                       MAGNACARE
   AETNA OPEN ACCESS            CROSS/BLUE SHIELD                   MASTERCARE
HMO                             MEDIBLUE (Medicare)                 MEDICAID
   AETNA PPO                      EMPIRE BLUE                       MEDICAID SECONDARY
   AFFINITY CHILD               CROSS/BLUE SHIELD PPO            TO MEDICARE
HEALTH PLUS                       FAMILY HEALTH PLUS                MEDICARE
   AFFINITY FAMILY                FIDELIS CHILD HEALTH              METROPLUS CHILD
HEALTH PLUS                     PLUS                             HEALTH PLUS
   AFFINITY MEDICAID              FIDELIS FAMILY                    METROPLUS FAMILY
   AFFINITY MEDICARE            HEALTH PLUS                      HEALTH PLUS
   AMERICHOICE (United            FIDELIS MEDICAID                  METROPLUS MEDICAID
Medicaid)                         FIDELIS MEDICARE                  METROPLUS MEDICARE
   AMERICHOICE CHILD              FIRST HEALTH                      MULTIPLAN (includes
HEALTH PLUS                       GALAXY                         Allied)
   AMERICHOICE FAMILY             GHI HMO CHILD                     NEIGHBORHOOD CHILD
HEALTH PLUS                     HEALTH PLUS                      HEALTH PLUS
   AMERIGROUP CHILD               GHI HMO COMMERCIAL                NEIGHBORHOOD
HEALTH PLUS                       GHI HMO FAMILY                 FAMILY HEALTH PLUS
   AMERIGROUP FAMILY            HEALTH PLUS                         NEIGHBORHOOD
HEALTH PLUS                       GHI HMO MEDICAID               MEDICAID
    AMERIGROUP                    GHI PPO (CBP For NYC              NEIGHBORHOOD
MEDICAID                        Employees & Medicare)            MEDICARE
   AMERIHEALTH                    GREAT WEST (formerly              NO FAULT
   ANTHEM                       One Health)                         ONE HEALTH PLAN
   ATLANTIS HMO                   GUARDIAN                       (Great West/New England)
   BC/BS OF NY (Major             HEALTHFIRST CHILD                 OXFORD FREEDOM
Medical)                        HEALTH PLUS                         OXFORD LIBERTY
   BEECH STREET                   HEALTHFIRST FAMILY                OXFORD MEDICARE
   BETTER HEALTH                HEALTH PLUS                      (Secure Horizons)
ADVANTAGE                         HEALTHFIRST                       PHYSICIANS HEALTH
   CAMBRIDGE                    MEDICAID                         SERVICE (Healthnet)
   CENTERCARE CHILD               HEALTHFIRST                       PRIVATE HEALTHCARE
HEALTH PLUS                     MEDICARE                         SYSTEMS (PHCS)
   CENTERCARE FAMILY              HEALTHNET (formerly               RAILROAD MEDICARE
HEALTH PLUS                     PHS)                                SELECT PRO
   CENTERCARE                     HEALTHPLUS CHILD                  UNITED HEALTHCARE
MEDICAID                        HEALTH PLUS                         UNITED HEALTHCARE
   CHILD HEALTH PLUS              HEALTHPLUS FAMILY              EMPIRE PLAN
   CHN                          HEALTH PLUS                         UNITED HEALTHCARE
   CIGNA                          HEALTH PLUS                    HMO
   CIGNA HMO (Open              MEDICAID                            UNITED HEALTHCARE
Access)                           HIP CHILD HEALTH               MEDICAID (Americhoice)
   CIGNA PPO                    PLUS                                UNITED HEALTHCARE
   COMPREHENSIVE CARE             HIP FAMILY HEALTH              MEDICARE (Secure Horizons)
MANAGEMENT                      PLUS                                UNITED HEALTHCARE
   COST CARE                      HIP HMO                        PPO
  VIDACARE                                    WELLCARE MEDICAID                         OTHER
  WELLCARE CHILD                              WORKER’S COMP                             OTHER
HEALTH PLUS                                                                             OTHER
  WELLCARE FAMILY                                                                       OTHER
HEALTH PLUS                                   OTHER


In addition to this form, we need a copy of your CV. Please send this form and your CV to:
                          Ms. Janice Boylan
                          Continuum Referral Service
                          555 West 57th Street, 18th floor
                          New York, NY 10019
                          Fax: (212) 420-2180
                          Jboylan@chpnet.org

I authorize Continuum Health Partners, Inc. to give my name and credentials to members of the community who
seek health care services.

Physician signature _______________________________________________ Date

If you have a short biographical sketch that you would like to appear on your Web profile, please email it to Janice
Boylan at jboylan@chpnet.org.

				
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